The strategy of initial assessment and emergent management of severe rauma has come up several times in the past papers. It has not appeared recently, but rather has become split up into sub-specialist injuries (eg. recently the approch to managing life-threatening neck wounds was asked about). ATLS principles generally follow the ABCDE algorithm and the most important component is the resolution of each problem as it is discovered.

Previous questions about the main ATLS algorithm have been as follows:

Question 8 from the first paper of 2009 (diaphragmatic rupture; value of the PR in trauma)

Airway

This is the point where you should look for facial fractures, foreign bodies, vomit and facial burns

When their ability to maintain an airway is at all in doubt, intubate them

Inline stabilisation of the C-spine throughout

Posterior dislocation of the clavicular head can cause an obstruction of the trachea. You need to reduce this, or you wont be able to ventilate. You can either hyper-extend the shoulders, or grab the clavicle with something like a clamp or towel clip, and manually drag it anteriorly, out of the airway. This reduction will usually be stable after you do this.

Breathing

Expose the chest

Watch chest excursion: symmetrical?

Auscultate: equal air entry?

Palpate the midline-ness of the trachea and the rest of the chest, looking for surgical emphysema

Percuss the chest looking for hyper-resonance of tension pneumothorax, or dullness of haemothorax.

Tension pneumothorax,open pneumothorax, massive haemothorax,flail chest - these should be identified during the primary survey

High FiO2 should be administered. One should look for paradoxical respiration pattern due to flail chest, or diaphragmatic breathing due to high spinal cord injury.

Circulation

Circulatory assessment may be clinical at this stage, or a blood pressure may be available.

Features of hypovolemia (eg. cool peripheries, pallor) should be sought. Blood should be sampled for crossmatch, and uncrossmatched blood should be transfused if the patient is demonstrating features of anaemia.

Adjuncts to the primary survey:

After the completion of the primary survey, the following investigations must urgently take place:

Bloods:

FBC

EUC

CMP

LFT

Coags

Crossmatch

Imaging

Chest Xray

FAST including pericardium

Pelvic Xray

Long bone Xrays

CT trauma series including aortogram

Monitoring

ECG

Urine output, IDC

Arterial invasive blood pressure

ICP monitoring may be indicated if the intracranial pressure cannot be monitored clinically

Secondary survey

This is a head-to-toe examination, including an AMPLE history:

Allergies

Medications

Past history

Last meal

Events and environment of the injury

Key features:

It is more important to identify a problem (e.g. significant abdominal pain) than the exact diagnosis (spleen laceration)

A checklist should be used to prevent missed injuries

A standardised sequence of examination should be followed, so that the examination can be reproduced if needed

Traumatic diaphragmatic rupture

Why is this here? It's is usually pretty obscure. However, it was a part of Question 8 from the first paper of 2009. Radiological findings are usually all the findings you get. The CXR is usually diagnostic. One can occasionally unearth some of the following (non-specific) clinical features:

Hypoxia

Decreased air entry on the affected side

Decreased chest excursion on the affected side

Dull percussion note

Bowel sounds in the chest

Ileus and bowel obstruction due to volvulus

Shoulder pain

Stool or bile in the chest drain

Tertiary survey

This is a post-operative repeat of the primary and secondary survey, usually performed in the ICU after all the dust has settled. During this review, a catalogue of remaining injuries and problems is made. Frequently missed injuries are uncovered during this survey (Biffl et al, 2003) - after the implementation of this practice the rate of missed injuries decreased from 5.7% to 3.4% at a busy Rhode Island trauma ICU. In that specific study, the tertiatry survey consisted of a second complete head to toe examination as well as a review of all imaging, within 24 hours of admission.

Key features:

A standardised sequence of examination should be followed, so that the examination from the secondary survey can be reproduced and referred to (eg. "were those testes always black? let's see what they found at the secondary survery")

The patients in whom this is of greatest importance are patients with a decreased level of consciousness (who cannot report the pain of a lacerated tendon in the index finger on their dominant hand, or something equally disabling in the long term)

Ideally, a person who is not familiar with the patient should be involved gotther with a person who is familair, so as to guard against complacency of the repeat examiner.